An assisted living center for people with dementia has been fined $6,000 for a serious medication error that resulted in a resident’s hospitalization.
State inspectors allege that on Dec. 23, 2025, a resident of Navigate Memory Care at Featherstone in Iowa City was prescribed Methotrexate, a drug commonly used to slow the growth of cancer cells, to be delivered at a rate of 15 milligrams per week.
On Dec. 26, 2025, a nurse at the facility, which is part of the Featherstone at Hickory Hill complex, incorrectly entered the dosage into the home’s computer system at 15 milligrams per day.
The computer immediately issued a warning indicating the dosage exceeded the usual recommendations, but the nurse “overrode the warning,” according to inspectors. Later, the home’s pharmacy faxed the facility a document questioning the dose, but no one at Navigate responded, according to inspectors.
The staff then began administering the drug on a daily basis. A pharmacist allegedly sent a second fax to the home on Dec. 29, 2025, asking the staff to clarify the dosage. The staff nurse responded with a note stating the resident “gets meds from a different pharmacy” and did not address the dosage issue, according to inspectors.
Two workers at the home later told inspectors they alerted the nurse to the fact that the dosage on the bottle of Methotrexate did not match the dosage listed in the electronic records. They reportedly stated the nurse was dismissive and advised them to follow the orders in the electronic record.
On Jan. 5, 2026, the resident was diagnosed with a bacterial skin infection and four days later, she was bleeding from the nose and was sent to a hospital with what inspectors describe as “painful mouth lesions.” She was diagnosed with neutropenia — a critical condition defined by a drop in blood cells – and was admitted for suspected Methotrexate toxicity. She was then given four units of red blood cells and two units of platelets, which eventually led to her stabilization.
The state fined the home $6,000.